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Abstract
Aspergers syndrome (AS) is a form of autism spectrum disorder (ASD) affecting many individuals today. Although
neurobiological correlates for AS have been identified, like many ASDs, AS is not completely understood. AS as a
distinct disorder is also not universally accepted and in the DSM-5 AS is not considered a separate nosological
entity. In contrast to some other ASDs, individuals with AS are commonly characterized by having standard or
higher than average intelligence, yet difficulties in social skills and communication can present challenges for these
individuals in everyday functioning. Counseling a person with AS or autism presents a unique challenge for the
mental health care provider. We have compiled this review consisting of some recent ideas regarding counseling
the client with AS with the goal of providing some clinical insights and practical clues. Although the focus of the
present paper is largely on AS, many of these strategies could also apply to individuals with high-functioning
autism (HFA).
Keywords: Asperger, Autism, Counseling, ASD, Autistic, High-functioning-autism
Introduction
Autism spectrum disorders (ASDs), including Aspergers
syndrome (AS), have been by the presence of a triad of
impairments: 1) social deficits, 2) repetitive/stereotypical
behaviors and interests and 3) communication difficulties
[1]. Additional ASDs have in the past included Autism and
pervasive developmental disorder not otherwise specified
(PDD-NOS) [2]. AS was originally described by Asperger
in 1944 [3] but was not included in the DSM-IV until 1994
[4]. In May 2013 the DSM-5 was introduced, subsuming
both AS and PDD-NOS under the umbrella term ASD.
This will now be used to classify all of the discrete autistic
disorders previously classified separately on the DSM-IV.
Clinical aspects are divided into a dyad of impairments:
1) persistent deficits in social communication issues and
2) restricted, repetitive behavior, interests and activities [5].
The extent to which the DSM-IV and DSM-5 diagnoses
will overlap is currently uncertain and concerns have been
expressed that some individuals previously diagnosed with
* Correspondence: awoods@clarkson.edu
1
Chemistry and Biomolecular Science, Clarkson University, 8 Clarkson Avenue,
Potsdam, NY 13699-5810, USA
2
Neuropsychology Clinic and Psychoeducation Services, SUNY Plattsburgh,
Plattsburgh, NY 12901, USA
Full list of author information is available at the end of the article
Prevalence
Recent estimates indicate that 1 in 88 US children have
an ASD, including AS. ASDs in general occur more frequently in boys than girls; one in 54 boys and one in 252
girls are affected [12] and this gender bias is also true of
AS. A United States government survey (Centers for Disease Control and Prevention; CDC) of parents indicates
2013 Woods et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.
Woods et al. Child and Adolescent Psychiatry and Mental Health 2013, 7:32
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neuroimaging studies have further supported neuroanatomical differences in AS versus HFA [25,26]. A recent article utilizing EEG examined patients aged 212, diagnosed
with either ASD (n = 430) or AS (n = 26). Neurotypical
controls were also studied (n = 554). Although the individuals with AS were neurophysiologically more similar to individuals with ASD than controls, they also appeared to
represent a population that could be distinguished from
subjects with ASD, based on EEG patterns [27]. In contrast, a meta-analysis of gray matter abnormalities in ASD
(24 data sets) failed to identify differences in overall or regional gray matter volumes between individuals with autism versus AS [28]. A diagnostic study has suggested that
distinctions among subtypes of ASDs, specifically autistic
disorder, PDD-NOS and AS, were not reliable across sites
using standardized diagnostic tools [29].
As mentioned, the DSM-5 does not distinguish between
AS and autism, while the ICD-10 does. Although the term
AS is used throughout this paper and the sources cited
largely also assume that AS is a distinct diagnosis, we also
acknowledge the possibility that autism and AS are the
same condition. Equally, it may prove to be the case that
there are a range of distinct ASD conditions that can be
discriminated. This issue is the subject of continuing research. Over the period from 2000 to 2012 studies published on AS using ICD or DSM diagnosed populations
were based on broadly comparable criteria, while earlier
work varied in the AS criteria employed.
It should be noted that the literature on treatment
differs in the diagnostic criteria used and clinical groups
studied. The therapeutic strategies reviewed may apply
to individuals with AS or HFA regardless of the diagnostic definition used, but their applicability needs to
be tested where only work with AS or autism has been
reported.
Social difficulties
Individuals with AS may have conventional vocabularies
but they typically have problems with social communication, particularly conversation, non-verbal cues and reciprocal interaction [30-33]. They have been said to have
difficulties in empathy and theory-of-mind (the ability to
distinguish between ones own mental state and that of
others) [34,35]. Individuals with AS may have trouble
processing social meaning due to having these challenges.
According to one study comparing 15 adults diagnosed
with AS versus 15 non-ASD control subjects, adults with
AS experience social cognition deficits, including the
decreased ability to implicitly encode and integrate contextual information to access social meaning. However, if
abstract rules specific to a social situation are presented,
or if social information is given in an explicit manner,
adults with AS can perform in a social situation more appropriately [36].
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Restricted interests
Individuals with AS may have extremely restricted interests. In some cases (though not always), restricted
interests can manifest as special interests ie., hobbies. One clinician has suggested that the special interests of AS clients can be utilized in counseling, for
example, a client with a special interest in Star Trek
was once asked what would Mr. Spock do in a situation like this? [8]. Asking the client about interests
may also serve as an initial means for developing an
alliance and increasing the comfort of the client with the
therapy setting [37,42]. One client with AS discussed
the composition of meteors at length when asked about
them by a therapist and seemed pleased to be consulted
about his expertise on the subject. This initial half hour of
discussion preceded a final 20 minutes of greater selfdisclosure and seemingly more comfort with the therapy setting.
Linguistics
Individuals with AS typically speak fluently but have
problems engaging in reciprocal conversation. Their conversational tone may be unusual and/or pedantic. Clients
with AS may have difficulty understanding metaphors
[53]. For example, in response to the phrase have your
cake and eat it too a client with AS stated I dont understand what that means, except that it has something
to do with cake. It has been proposed that difficulties
with metaphors may be attributed to difficulties in processing language in the right hemisphere [53]. The right
hemisphere is more responsible for distant and figurative
meaning, as opposed to the more literal meanings of
words processed by the left hemisphere [54]. Irony and implied meaning can also be confusing to a person with AS
[55]. These traits can also become apparent within the
counseling setting and the counselor may therefore want
to speak to a client with AS using very literal language and
avoid metaphors or figures of speech. In general, it may be
helpful to take a direct, instructional approach versus a
more indirect approach that encourages clients to uncover
solutions to their own problems [35]. This approach may
be counter-intuitive to many therapists.
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Emotionality
Emotion and emotional reactions may be difficult for individuals with AS to process and discuss. This can include the expression of emotions, understanding the
emotions of others, and emotion regulation. Individuals
with AS may not have diminished emotionality, however
it may be more accurate to say that individuals with AS
have greater difficulties in understanding and compartmentalizing their own emotions or in conveying these to
others.
Neuroimaging studies have indeed shown that in people
with AS the amygdala and hippocampusinterconnected
brain regions essential to processing emotions and emotional memoriesappear to have differences in their neuronal and lipid composition relative to non-AS controls
[56]. It may be that emotions overwhelm people with AS,
increasing their inability to manage them. Depression and
anxiety higher in people with AS than in the general population [57]. Depression and anxiety may be further exacerbated by the fact that people with AS are often victims of
bullying and abuse, likely due to their social awkwardness
[8]. Therapists treating individuals with AS may therefore
consider screening for mood disorders as part of the therapy initiation process. One study has suggested that individuals with autism in general tend to express anxiety
through changes in their behavior rather than verbally.
Therapists may therefore note that depression and anxiety
will not always be verbalized by the client, but may become
apparent through behavioral changes [58].
A randomized controlled trial examining a six-week
cognitive behavioral intervention demonstrated decreased
anger episodes in 24 children with AS relative to 21 children with AS who did not undergo the intervention [59].
Single subject case reports have additionally suggested that
cognitive behavioral therapy (CBT) can be successful at
treating anxiety, depression and social problems in clients
with AS [60,61]. CBT, specifically in a group setting, was
also found to be helpful for adults with AS or mood disorders [57]. The authors of a three case-study report suggested that group therapy could be more effective than
individual therapy for people with AS because it provides
often isolated individuals with AS with support and also
opportunities for social learning, which is greatly needed
by individuals with AS. The authors of this report also
noted that the three participants appreciated the structure
and scientific nature of CBT and their ability to chart their
progress [57]. In addition to the use of CBT for managing
ones own emotions, interactive media have also been
employed to teach adults with AS to effectively learn to
recognize complex emotions in others [62]. Based on these
studies, emotional problems can be effectively treated in
individuals with AS. There is supporting evidence for a
CBT approach either working individually or in a group
format. This conclusion is supported by several studies.
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Competing interests
The authors declare that they have no competing interests.
Authors contributions
AGW was responsible for writing the manuscript. EM and JR commented
on the written drafts of the manuscript. All authors read and approved
the final manuscript.
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Acknowledgements
AGW would like to thank her clients with AS for teaching her and Dr. Costel
Darie for helpful input into the manuscript. We also thank SciFund Challenge
donors, Mary Stewart Joyce, Ken Sandler and Bob Matloff for supporting our
autism research.
Author details
Chemistry and Biomolecular Science, Clarkson University, 8 Clarkson Avenue,
Potsdam, NY 13699-5810, USA. 2Neuropsychology Clinic and
Psychoeducation Services, SUNY Plattsburgh, Plattsburgh, NY 12901, USA.
3
Mental Health Counseling Program, College of Education and Human
Development, University of Massachusetts, Boston, 100 Morrissey Blvd,
Boston, MA 02125, USA.
1
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doi:10.1186/1753-2000-7-32
Cite this article as: Woods et al.: Treating clients with Aspergers
syndrome and autism. Child and Adolescent Psychiatry and Mental Health
2013 7:32.